This guide provides an overview of how to perform a hernia examination in an OSCE setting. It also includes a generic approach to assessing lumps and discusses how to differentiate between direct and indirect inguinal hernias.
You can check out the hernia examination OSCE mark scheme here.
Wash your hands
Confirm the patient’s details (e.g.name and date of birth)
Explain the procedure:
- “Today I need to perform an examination of the lump you are concerned about, which will involve me having a look and feel of the lump.”
- “It shouldn’t be painful, however, it might be a little uncomfortable. If at any point you are in pain or would like me to stop, just let me know.”
- “For this examination, I will need you to have your trousers and underwear off to allow me to assess the lump. If you feel uncomfortable at any point, let me know and we can stop the examination.”
Explain the need for a chaperone:
- “For this examination one of the nursing staff will be present acting as a chaperone.”
Check the patient’s understanding and gain consent:
- “Do you understand everything I’ve explained?”
- “Do you have any questions?”
- “Are you happy for me to perform the procedure?”
Check if the patient has any pain before you begin:
- “Are you currently experiencing pain anywhere?”
Ask the patient to stand (if able) or lay down whilst you observe for the following:
- Note any evidence of pain (e.g. stance/grimacing)
- Note the patient’s overall colour (e.g. pallor secondary to anaemia or jaundice)
- Note any evidence of abdominal distension (may suggest bowel obstruction, possibly due to an incarcerated hernia)
- Note any muscle wasting or cachexia suggestive of underlying malignancy
- Look around the bed for evidence of vomit bowels or medication boxes
1. Inspect the patient from the front and both sides (whilst the patient is standing or lying down), looking for evidence of:
- Scars on the abdomen and in the groin
- Obvious lumps protruding from the abdomen or groin
- Any testicular lumps or swellings
2. Ask the patient to cough, which should accentuate any hernia that is present.
Assessing a Lump
Throughout the examination, it is important to explain to the patient what you are about to do next, to ensure they are informed and can voice any concerns.
A Generic Approach to Assessing a Lump
If a lump is noted during the inspection, you should start with a generic lump assessment, before moving onto a more specific hernia assessment.
- Be precise (e.g. mid-point of the inguinal canal)
- If there are multiple lumps, this is more suggestive of superficial lymph nodes, superficial lesions (e.g. lipoma) or dermatological problems (e.g. large skin lesions)
- Use a tape measure if available (otherwise, a shortcut is to measure and memorise the length of the distal phalanx of your index finger, and use that as a reference)
- This refers to the whole outline of the lump (e.g. round/oval/irregular/well-defined)
- Is the lump a different colour from the surrounding skin (e.g. erythematous)?
- This refers to the look and texture of the skin overlying the lump
- Is it same as rest of the skin, or thick/rough/scaly/smooth/shiny?
- Comment whether the lump is hard, firm, soft or nodular
- Hard corresponds to the feel of your forehead, firm to the tip of your nose, and soft to your lip
- Press on the lump and look at the patient’s face to see if they grimace
- Ask the patient if the lump is painful
- Is the whole lump tender or just a part of it?
- Palpate the temperature using the back of your hand, comparing to surrounding tissue
- Significantly increased temperature suggests infection (e.g. abscess) and will normally be associated with erythema
- Is the lump freely mobile, or is it tethered to a structure such as skin or muscle?
- Malignant lumps are often fixed to surrounding tissue
- Ask the patient to cough whilst you palpate the lump
- A positive cough impulse occurs when you see and/or feel the lump increase in size when the patient coughs
- A cough impulse indicates a communication between the intra-abdominal cavity and the lump (e.g. a hernia)
- Ideally dim the lights in the room first
- Shine a light through the lump and see if it illuminates
- Transillumination suggests that the lump is cystic (e.g. hydrocoele)
- Auscultate the lump for a bruit (suggestive of vascular aetiology)
- Listen for bowel sounds and if present, it suggests the lump contains bowel (e.g. as is often the case in a hernia)
- Palpate the lymph nodes that drain the area the lump is located within (commonly the inguinal lymph nodes are assessed when an inguinal hernia is suspected)
- Lymphadenopathy surrounding the lump suggests either infective or malignant aetiology
Assessment of a suspected hernia
The following hernia assessment should be performed on both sides of the groin, to avoid missing bilateral inguinal hernias.
Types of Hernia
It is important to understand the different types of hernia and the related anatomy, as this helps inform your clinical examination technique and interpretation of findings. Below is a very brief summary of hernia types, but you can read more in our Hernias Explained article.
An inguinal hernia is a protrusion, or movement of abdominal contents, from within the abdominal cavity. This tissue then protrudes, or emerges, at the exit point, the superficial inguinal ring.
LOCATION: Inguinal hernias are most commonly found superomedial to the pubic tubercle.
Femoral hernias occur just below the inguinal ligament, when abdominal contents pass through a naturally occurring weakness in the abdominal wall called the femoral canal.
It is important to note that the space a femoral hernia protrudes through is quite tight, and it is bordered medially by the sharp edge of the lacunar ligament. Therefore, femoral hernias are at high risk of strangulation and obstruction.
LOCATION: Femoral hernias are typically found infero-lateral to the pubic tubercle (and medial to the femoral pulse).
Umbilical hernias, as the name suggests, occur at the site of the umbilicus and are common. They can be large but are typically low risk for strangulation.
LOCATION: Umbilical region
Incisional hernias occur at the sites of previous operations, where there has been incompletely-healed (weakened) surgical wound.
LOCATION: Clinically, incisional hernias present as a bulge or protrusion at or near the area of a surgical incision
Position of Hernia
- Above and medial to the pubic tubercle: Inguinal hernia
- Below and lateral to the pubic tubercle: Femoral hernia
- Umbilical region: Umbilical/para-umbilical hernia
- Check it the lump can be reduced (you can ask the patient to do this, or do it yourself)
- If reduced completely, it may only reappear if the patient increases pressure (e.g. by coughing)
- You can ask the patient to lie down and if the lump reduces spontaneously, this makes the diagnosis of a hernia highly likely.
- Hernias are typically reducible, however, if a hernia is painful and irreducible it suggests that it is strangulated (this is a surgical emergency)
Direct vs Indirect Inguinal Hernia
- Locate the deep inguinal ring (midway between the anterior superior iliac spine and pubic tubercle)
- Ask the patient to reduce their hernia (if able) or alternatively reduce it yourself by starting inferiorly compressing the lump towards the deep inguinal ring
- Once reduced, apply pressure over the deep inguinal ring
- Ask the patient to cough
- If a hernia reappears it is more likely to be a direct inguinal hernia whereas if it does not, it is more likely to be an indirect inguinal hernia
- In the latter case, release the pressure from the deep inguinal ring and observe for the hernia reappearing (further supporting the diagnosis of an indirect inguinal hernia)
- It should be noted that this clinical test is unreliable and further imaging (e.g. ultrasound scan) would be required before any management decisions were made
- Inguinal hernias can extend into the scrotum, so if you note swelling or suspect an inguinal hernia, palpation of the scrotum can be performed (with consent)
- Typically, an inguinal hernia will present as a testicular lump that you can not get above
- Auscultation of a hernia can be used to assess for the presence of bowel (bowel sounds will be present)
To complete the examination…
- Thank the patient
- Allow the patient time to get re-dressed
- Document the examination in the medical notes including the details of the chaperone
“On examination of Mr Smith, a 52-year-old gentleman, there was a round mass visible in the left groin above and medial to the pubic tubercle. It was non-tender, approximately 2cm in diameter, soft in consistency and reducible. There was a positive cough impulse and the hernia recurred despite pressure over the deep inguinal ring. There was no extension to the scrotum and no associated lymphadenopathy. The most likely diagnosis based on my clinical findings is a direct inguinal hernia. ”
Suggest further assessments and investigations
- Abdominal examination
- Testicular examination (if not already performed)
- Assessment of the inguinal lymph nodes (if not already performed)
- Further imaging (e.g. ultrasound/CT)
1. By James Heilman, MD [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0) or GFDL (http://www.gnu.org/copyleft/fdl.html)], from Wikimedia Commons
2. By PacoPeramo [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)], from Wikimedia Commons